Provider Demographics
NPI:1427411958
Name:DEMO, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:DEMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2053 GAUSE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5449
Mailing Address - Country:US
Mailing Address - Phone:985-649-1001
Mailing Address - Fax:985-646-1005
Practice Address - Street 1:2053 GAUSE BLVD E
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5449
Practice Address - Country:US
Practice Address - Phone:985-649-1001
Practice Address - Fax:985-646-1005
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007748640101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor